Nurse practitioners in home-based prepalliative care demonstrate an innovative, value-based approach to end-of-life care planning.

BACKGROUND: Nurse practitioners (NPs) demonstrate value-based, home-based primary health care (HBPC) to home-bound patients with high disease burden at reduced cost. PURPOSE: The research questions were as follows: (a) Does patient-centered, prepalliative care delivered by HBPC NPs decrease number of hospitalizations and emergency department (ED) visits and increase patient satisfaction? and (b) What are the criteria for patients to receive end-of-life (EOL) discussions by NPs? METHODOLOGY: This was a quasi-experimental, retrospective two-group design with a convenience sample of 233 HBPC patients from an academic clinical partnership compared with 234 clinic patients matched on age and Charlson Comorbidity Index (CCI) score over 4 years. Measures included signed advanced directives (ADRs), medical orders of life-sustaining treatment (MOLST) forms, number and length of home visits, hospitalizations, and ED visits after diagnosis. Chi-square analyses and general linear models using a Poisson distribution were conducted. RESULTS: Home-based primary health care patients had higher disease burden, statistically higher CCI scores, and signed ADR and MOLST agreements more often than clinic patients with significantly fewer hospitalizations and ED visits, and longer visits with providers. CONCLUSIONS: Patients receiving HBPC for prepalliative, EOL illness benefit from more time to discuss the difficult factors surrounding access to care for those with life-threatening illnesses. IMPLICATIONS: Recipients of prepalliative HBPC by NPs could require fewer provider visits, hospitalizations and ED visits, patient satisfaction, and a potential decrease in health care spending at EOL.

Use of social determinants of health codes in home-based primary care.

BACKGROUND: The Affordable Care Act created funding for nurse practitioner education programs to transform the primary health care workforce through student awareness of how social, political, economic, and environmental factors influence individual and population health. Funding established Academic Clinical Partnerships (ACPs) that created value-based health care models, which improved patient outcomes and decreased hospital and emergency department admissions and health care costs. The ACP established a home-based primary health care (HBPC) program to deliver primary care and collect patient data. PURPOSE: The purposes were to describe the incidence of chronic conditions for HBPC patients and determine associations between chronic conditions and presence of social determinants of health (SDoH). METHODOLOGY: Nurse practitioner students were assigned to HBPC clinical placements. A convenience sample of 102 high-risk, homebound patients was identified. Nurse practitioners and students recorded deidentified patient data, including ICD-10-CM codes into a Health Insurance Portability and Accountability Act compliant platform. Secondary analysis of patient records assessed for SDoH through Z codes. RESULTS: Patients had high incidences of hypertension, diabetes, pulmonary disease, heart disease, chronic pain, mood, and substance abuse disorders. Secondary analysis revealed that 92% of patients had indications for the use of Z codes, but these were not recorded. CONCLUSIONS: Common Z codes were personal risk factors, housing/economic circumstances, care provider dependency, lifestyle, and family support. IMPLICATIONS FOR PRACTICE: By coding for SDoH, providers and agencies can realize higher reimbursement rates in HBPC settings. Nurse practitioners can use this information to provide better treatment recommendations, more accurate diagnoses, and referrals to enhance primary care services to a patient population negatively affected by SDoH.

Prematurity and cardiovascular risk at early adulthood.

BACKGROUND: Theories of early stress exposure and allostatic load offer a lifespan perspective to adult health after prematurity based on these early stressors affecting endocrine and metabolic systems. In this study, we examine cardiovascular and metabolic risk by comparing two groups of preterm infants who experienced a full spectrum of neonatal illness and a term-born group at age 23. METHODS: Of the 215 infants recruited at birth, 84% participated at age 23. The cohort included 45 full-term (FT), 24 healthy preterm (HPT), and 111 sick preterm (SPT) infants. Socio-economic status was equivalent across groups. Cardiovascular and metabolic outcomes were as follows: blood pressure (BP), fasting glucose and lipid profiles, weight, waist-hip ratio (WHR), and body mass index (BMI). Clinical and subclinical ranges were compared across neonatal groups and gender. RESULTS: At age 23, the HPT and SPT groups had higher systolic BP compared with the FT group. The SPT group had lower weight compared with the FT and HPT groups. No group differences were found on diastolic BP, glucose, total cholesterol, high-density lipids, low-density lipids, triglycerides, BMI, or WHR. Preterm males had more systolic hypertension and low high-density lipids than FT males. Former preterm males and females had high WHR ratios and BMI at 23 years. Subclinical prehypertensive rates were highest for the HPT female group, followed by the SPT females. Only one (4.2%) HPT adult male was clinically diabetic. CONCLUSIONS: As young adults, HPT and SPT infants had early indicators of cardiovascular risk but no indicators of metabolic risk. There is utility in using clinical and subclinical ranges to identify early cardiovascular risk in early adulthood.

Home-based nurse practitioners demonstrate reductions in rehospitalizations and emergency department visits in a clinically complex patient population through an academic-clinical partnership.

BACKGROUND AND PURPOSE: The purpose of this pilot study was to describe the impact of one aspect of an academic-clinical partnership that showed how assigning nurse practitioner faculty to deliver home-based primary care services to clinically complex patients would decrease rehospitalizations and emergency department visit rates. METHODS: Rehospitalizations and emergency department visits of a cohort of 82 patients were recorded from April 15, 2016 to August 25, 2016 and compared with the same cohort during the two pre-home care inception periods (6 months and 1 year) using insurance claims-based data. CONCLUSIONS: Compared with the 1-year pre-home care inception period, there was a decrease of 23.7% in emergency department visits and 34.9% decrease in rehospitalizations after the implementation of the home-based primary care program and a decrease of 35.6% in emergency department visits and 59.4% decrease in rehospitalizations compared with 6 months of pre-home care inception. IMPLICATIONS FOR PRACTICE: Allowing nurse practitioners with full practice authority to deliver home-based primary health care services to homebound, chronically ill, recently discharged, and/or disabled patients can decrease costs and promote optimum health care in this population. In addition, these programs provide valuable learning experiences for nurse practitioner students and their preceptors.

Trajectories of problem behaviors from 4 to 23 years in former preterm infants.

Premature infants have significant risk for later behavior problems. This study examined growth trajectories of three problem behaviors across five developmental age points from preschool to early adulthood in a well-characterized sample of premature infants. The effects of neonatal risk, gender, and socioeconomic context were modeled on these trajectories. The longitudinal sample was comprised of preterm infants (N = 160) with full variation of neonatal morbidity and birth weight (640-1950 grams). Trajectories of externalizing, internalizing and attention problem behaviors from 4 to 23 years, measured by the Child Behavior Checklist, were tested using latent growth curve modeling. The results indicate individual variation in the number of externalizing and internalizing problems over time. Externalizing problems were not significantly different for males and females, but male scores were consistently higher. Neonatal risk was significantly associated with higher internalizing problems at age 4, but was not predictive at school age and beyond. Attention problem scores increased from early preschool through adolescence for males, but females had little change over the same ages. SES was not predictive of any problem behavior trajectories and no significant two-way interactions were found. The results advance understanding of stability and change of three important problem behaviors through preschool, childhood and adolescence to young adulthood in prematurely born infants in order to inform clinicians about timely assessment and the refinement of effective interventions.

Prematurity, Birth Weight, and Socioeconomic Status Are Linked to Atypical Diurnal Hypothalamic-Pituitary-Adrenal Axis Activity in Young Adults.

In a prospective, case-controlled longitudinal design, 180 preterm and fullterm infants who had been enrolled at birth participated in a comprehensive assessment battery at age 23. Of these, 149 young adults, 34 formerly full-term and 115 formerly preterm (22 healthy preterm, 48 with medical complications, 21 with neurological complications, and 24 small for gestational age) donated five saliva samples from a single day that were assayed for cortisol to assess diurnal variation of the hypothalamic-pituitary-adrenal (HPA) axis. Analyses were conducted to determine whether prematurity category, birth weight, and socioeconomic status were associated with differences in HPA axis function. Pre- and perinatal circumstances associated with prematurity influenced the activity of this environmentally sensitive physiological system. Results are consistent with the theory of Developmental Origins of Health and Disease and highlight a possible mechanism for the link between prematurity and health disparities later in life.

Characteristic Processes in Close Peer Friendships of Preterm Infants at Age 12.

Close friendships become important at middle-school age and are unexplored in adolescents born prematurely. The study aimed to characterize friendship behaviors of formerly preterm infants at age 12 and explore similarities and differences between preterm and full-term peers on dyadic friendship types. From the full sample of N=186, one hundred sixty-six 12-year-old adolescents (40 born full term, 126 born preterm) invited a close friend to a 1.5 hour videotaped laboratory play session. Twenty adolescents were unable to participate due to scheduling conflicts or developmental disability. Characteristic friendship behaviors were identified by Q-sort followed by Q-factoring analysis. Friendship duration, age, and contact differed between the full-term and preterm groups but friendship activities, behaviors, and quality were similar despite school service use. Three Q-factors, leadership, distancing, and mutual playfulness, were most characteristic of all dyads, regardless of prematurity. These prospective, longitudinal findings demonstrate diminished prematurity effects at adolescence in peer friendship behavior and reveal interpersonal dyadic processes that are important to peer group affiliation and other areas of competence.

Academic, social, and behavioral outcomes at age 12 of infants born preterm.

The effects of gradient levels of perinatal morbidity on school outcomes have been investigated at age 12 in four preterm groups, classified as healthy (no medical or neurological illness), medical morbidity, neurological morbidity, and small-for-gestational-age (SGA), and a full-term comparison group. Teachers report on academic competence, social skills, and problem behaviors. Data on school type, classroom setting, and school service use are gathered from school records. Preterm groups are found to be equivalent to full-term peers in social skills and problem behavior. Preterm groups with neurological and SGA morbidity have the lowest academic competence scores. Unexpectedly, preterm infants with medical morbidity have higher academic competence scores compared with the other preterm groups. School service use increases with greater perinatal morbidity and is contingent on multiple rather than single indicators of perinatal morbidity. Continued monitoring of preterm infants through early adolescence will ensure that appropriate school services and resources are available to maximize their school success.

Developmental origins theory from prematurity to adult disease.

Developmental Origins Theory has received little coverage in the nursing literature, even though it has received much attention in other sciences. The theory proposes that prenatal stress provokes adaptive changes in endocrine and metabolic processes that become permanently programmed and impact later adult health. This paper reviews the theory and describes the primary neuroendocrine mechanism of hypothalamic-pituitary-adrenal axis function. Supporting research evidence in preterm infant and adult samples is presented. Through knowledge of the theory and the long-term sequelae for preterm infants, nurses will have a different theoretical perspective and growing evidence to consider in their care for pregnant women and infants.